Words, Do No Harm
Stigmatizing language in medical records follows patients, potentially exacerbating racial inequities, says Mary Catherine Beach, who is on a mission to raise awareness among physicians.
In virtually every medical visit we have these days, the physician makes notes about the encounter — information that goes into our electronic medical record, which subsequent clinicians will read to help shape the care they provide.
Intentionally or not, those physician notes can include negative language about the visit — stigmatizing language that has the potential to influence the attitude and behavior of other clinicians who read the notes, says professor of medicine and bioethicist Mary Catherine Beach, whose research investigates how respect and communication play out between patients and clinicians.
“I fundamentally believe that stigmatizing language is dehumanizing. It devalues people,” says Beach. “And when negative language is used in a patient’s medical record, it has the potential to impact future care of the patient and perpetuate health inequities.”
In a qualitative study published in JAMA Network Open, Beach and her colleagues analyzed physician notes describing 600 patient encounters at an urban academic medical center.
The team found five themes representing negative language used by the providers.
These include notes that question a patient’s credibility (He claims that nicotine patches don’t work for him) and those that show explicit racial or class stereotyping (Reports that the bandage got “a li’l wet”). Other notes describe a difficult patient by including details of questionable clinical significance, and a fourth theme shows the provider’s disapproval, often by highlighting a patient’s poor reasoning (He was adamant that he does not have prostate cancer because “his bowels are working just fine”). Rounding out the list is a category Beach describes as unilateral decisions: paternalistic language that portrays the patient as childish or ignorant.
“When I present our findings to physician groups, rather than any defensiveness, I usually get a very positive response,” says Beach. “There’s often an, ‘Oh, yeah! We do write that,’” she says, adding, “Some of this language has been normal for so long, it didn’t hit us that it was wrong or that it could hurt people.’”
But words can hurt, she notes. Patients who have difficult interactions with the health care system are at risk of distrusting or disengaging from care. “And stigmatizing language used in the medical record compounds this problem,” she says, as the patient encounters clinicians in sequence, with each doctor treating the patient in accordance with the impressions expressed by the previous doctors. The cycle “perpetuates bias and inequitable care, further disenfranchising the patient.”
Fortunately, Beach’s study also came with positive findings — “language we can use to humanize our patients,” she says.
The six themes identified here include compliments (he is charming, pleasant, and kind), approval (she struggled with quitting … but as of this clinic visit has quit tobacco 1 week!) and physician self-disclosure, in which the provider shares their own positive emotions related to the patient (I am happy to continue coordinating her care).
Other positive themes: minimizing blame (she has not been taking iron because it makes her constipated); personalizing, which involves incorporating details about the patient as an individual; and bilateral decision-making, which references incorporating patient preferences into the treatment plan.
In the time since this study was published, “interest in our findings has just exploded,” Beach says. “I am asked every week by journal editors to serve as a reviewer for one or two other papers on stigmatizing language.” And she’s been approached by the nation’s two major medical records providers — Epic and Cerner — to join future working groups that will study how medical documentation can be improved by identifying and removing biased language.
“By enhancing awareness around physicians’ word choice patterns and the potential consequences of those patterns,” she says, “we believe well-intentioned doctors will be motivated to improve their documentation practices.”